PAPod 592 - How a Near-Miss Sparked the Learning Team Movement

Todd Conklin tells the origin story of "learning teams," sparked by a self-reported near-miss at Los Alamos involving a postdoc and an arcing wrench. Rather than pursuing a punitive investigation, a group of workers gathered to identify what needed to be learned, uncovering broader gaps in postdoc training and safety planning. The episode explains how learning teams prioritize asking better questions, collecting the right data, and designing system-focused solutions. Conklin describes how this approach spread across the lab and why it remains a fast, effective tool for operational improvement.

Todd Conklin talks with Corey Pitzer about fatality prevention, Human and Organizational Performance (HOP), and how safety thinking has shifted globally. They explore controversial views—treating workers as problem-solvers, tensions between engineering/energy-based approaches and systemic/new-view thinking—and use real examples to show why designing systems that absorb variation matters more than trying to eliminate risk.

Todd interviews Professor David Woods about recent NASA mishaps and a growing cultural shift toward "cheaper, faster" decision-making that sacrifices safety. They explore how past safety gains have lost vitality, highlight cascading modern risks (the "messy nine"), and argue for mutual assistance and revitalized resilience practices. Wood's most recent writing on this is available in the Bulletin of Atomic Scientists called:  Cheaper, Faster, and Who Gives a Damn about Anything Else. The episode connects space, aviation, cloud outages, and AI-driven engineering to show why coordinated foresight and cross-disciplinary cooperation are essential to prevent far-reaching harm in today’s complex systems.

In this episode, Todd Conklin joins Amir Shahzad to discuss human and organizational performance, resilience, and how to design systems that allow failures to be caught and recovered before they become disasters. They explore the gap between work as imagined and work as done, the value of learning from everyday work, and practical steps leaders can take to create safer, more resilient workplaces. They also cover cultural change, the role of procedures, adaptive behavior, and the potential—and risks—of AI in safety, all delivered with a mix of practical advice and light-hearted rapid-fire questions.

Hosts Todd and Brent discuss an upcoming restorative workshop centered on RaDonda Vought's account of the Emory Hospital event. The episode highlights how normal performance variability can combine into serious failures, the value of storytelling, and the importance of learning and building resilience across complex systems. The workshop in Santa Fe (March 31–April 1) invites healthcare and high‑risk industry professionals to move from “what” happened to “how” to apply lessons in practice. For more information or to register, contact [email protected].

Host Todd Conklin interviews fatigue expert Mark Rosekind, PhD about his path from sleep research to roles at NASA, the NTSB, and NHTSA, and how sleep science applies across transportation and safety-critical work. Key takeaways: think of sleep like a bank account (sleep debt), "start in the black" before major schedule changes, the benefits of strategic naps, and systemic ways organizations can reduce fatigue to improve performance, health, and safety.

Todd Conklin discusses VUCA (Volatility, Uncertainty, Complexity, Adaptation) and argues that innovation and safety improve when organizations embrace uncertainty and gather more diverse information and perspectives. He mixes personal travel and Olympics anecdotes, touches on aviation and healthcare examples, and invites listeners to a hands-on workshop to explore these ideas further.

In this clip from the Pre‑Accident Investigation Podcast and Punk Rock Safety, Todd joins Ron, Ben, and David to debate why safety innovation is stalling, where new ideas are coming from, and who’s pushing practice forward. They explore barriers like regulatory pressure, the pull of “normal,” and the difference between improving safety and redesigning work. Using examples from pediatric intensive care and other domains, the conversation highlights pockets of progress, the danger of idea corruption, and the need to embrace experimentation, rethink systems, and find the next generation of thinkers to advance safety practice.

This episode tells the real-life story of how the Society for Patient Safety and a network of children’s hospitals used learning teams, proactive safety huddles, and simulations to reduce unplanned extubations in neonatal ICUs — cutting rates by 60% and preventing thousands of deaths. It covers the data, the frontline-led solutions, the narrowing of racial disparities, and an invitation to a small conference in Santa Fe to learn and share improvement practices.

This episode previews a small workshop in Santa Fe where Todd Conklin, Ann Lyren, and guest ReDonda Vaught will explore a tragic patient safety case. They frame accidents as the unexpected combination of normal performance variability and discuss how to learn from such incidents. Listeners will hear about the meeting goals (March 31–April 1), opportunities to chart the event, and practical tactics for organizations to identify and respond to accumulating risks, with cross-industry lessons and a focus on improving safety culture.